Term
| What is the atrial rate in atrial fibrillation? ventricular rate? |
|
Definition
| atrial= 400-600; ventricular= 80-160 |
|
|
Term
| What is the risk of developing AF as you age? |
|
Definition
| doubles with each decade over age55; at age 80, prevalence is about 10% |
|
|
Term
| What are some causes of atrial fibrillation? |
|
Definition
| COPD, pulmonary embolism, pheochromocytoma, pericarditis, Ischemic heart disease, hypertension, rheumatic heart disease, anemia, atrial myxoma, thyrotoxicosis, ehtanol and cocaine, sepsis |
|
|
Term
| What is the most common symptom of atrial fibrillation? |
|
Definition
|
|
Term
| Describe the ECG of Afib? |
|
Definition
| narrowcomplex rhythm (QRS <120 msec), variable RR intervals and irrgular or absent P waves |
|
|
Term
| What workup is indicated for afib? |
|
Definition
|
|
Term
| How can you emergently control ventricular rate of a fib? |
|
Definition
| IV calcium channel blockers (diltiazem( or beta blocker (metoprolol); hypotension is an adverse medication reaction that may require immediate DC cardioversion |
|
|
Term
| What are some ways to control ventricular rate of nonemergent a fib? |
|
Definition
| oral beta blockers (atenolol) and calcium channel blockers (verapamil or diltiazem) +/- digoxin |
|
|
Term
| About what do you want the ventricular rate to be if you are treating tachycardia secondary to afib? |
|
Definition
| less than or equal to 80 bpm at rest and up to 110 with activity |
|
|
Term
| What drug do you use to convert a fib to sinus rhythm? |
|
Definition
|
|
Term
| What are contraindications to pharmacologic conversion of afib? |
|
Definition
| onset >1 month and severe left atrial dilatation (chamber >46 mm by echo) |
|
|
Term
| What is more successful for cardioversion of a fib, drugs or cardiovert? |
|
Definition
|
|
Term
| What voltage do you start out with to convert afib? |
|
Definition
|
|
Term
| What should you do before electric cardioversion of afib? |
|
Definition
| if arrhythmia has been present for >48 hours, the patient must either be anticoagulated with warfarin for 3-4 weeks before cardioversion or recieve TEE to exclude an atiral thrombus |
|
|
Term
| After succesful electric cardioversion of afib it is important to always... |
|
Definition
| anticoagulate pt for at least four weeks after cardioversion |
|
|
Term
| What are the two surgical techniques to treat afib? |
|
Definition
| open maze procedure or catheter ablation |
|
|
Term
| By what percent are you decreasing stroke risk in pts with afib when you anticoagulate them? |
|
Definition
| with aspirin decreases by 22%; with warfarin decreases by 62% |
|
|
Term
| What is the risk of stroke in pts with afib each year? |
|
Definition
|
|
Term
| What is the goal INR for anticoagulation of afib? |
|
Definition
|
|
Term
| What percent of elderly patients have CHF? |
|
Definition
|
|
Term
| Most people hospitalized for CHF are what age? |
|
Definition
|
|
Term
| What infections can cause CHF? |
|
Definition
| viral cardiomyopathy or HIV |
|
|
Term
| What is the most common cause of CHF? |
|
Definition
| chronic ischemic heart disease |
|
|
Term
| What are some common causes of CHF exacerbation in previously stable patients? |
|
Definition
| forgetting to take meds, arrhythmia, anemia, MI/ischemia, infection, increased salt intake, increased cardiac output (pregnancy, hyperthyroidism), renal failure, PE |
|
|
Term
| What is the most common cause of CHF in a previously stable patient? |
|
Definition
|
|
Term
| Name some causes of dilated cardiomyopathy? |
|
Definition
| idiopathic, drugs (ethanol, cocaine, heroin, doxorubicin), postmyocarditis, postpartum,HIV, Chagas, anemia, thiamine deficiency, thyrotoxicosis |
|
|
Term
| Hypertension causes what type of heart failure? |
|
Definition
| "hypertensive burnout"= initially a diastolic dysfunction but after the myofibrils stretch, the EF falls and systolic dysfunction results |
|
|
Term
| Valvular heart disease causes what type of heart failure? |
|
Definition
| initally diastolic dysfunction but later systolic dysfunction |
|
|
Term
| Systolic dysfunction can be caused by what two types of problems? |
|
Definition
| decreased contractility or increased afterload |
|
|
Term
| What are some common causes of increased afterload leading to decreased contractility? |
|
Definition
| HTN, aortic stenosis, ventricular dilation due to aortic insufficiency |
|
|
Term
| Diastolic dysfunction can be due to what two kinds of abnormalities? |
|
Definition
| abnormal active relaxation (ischemia, hypertrophic cardiomyopathy), abnormal passive filling (restrictive cardiomyopathy or concentric hypertrophy from hypertension) |
|
|
Term
| What is the least common cardiomyopathy? |
|
Definition
| restrictive cardiomyopathy |
|
|
Term
| What are some infiltrative disorders that can cause a restrictive cardiomyopathy? |
|
Definition
| sarcoidosis, amyloidosis, scleroderma, hemochromatosis, glycogen storage disease |
|
|
Term
| Systolic dysfunction is defined as an EF of... |
|
Definition
|
|
Term
| What are some early signs of left heart failure? |
|
Definition
| DOE; decreased exercise tolerance |
|
|
Term
| What are some early signs of right sided heart failure? |
|
Definition
| anorexia, cyanosis and fatigue, increased JV, pulsatile hepatomegaly (with possible transaminitis), peripheral edema on exam |
|
|
Term
| Is tachycardia a sign of left heart failure or right heart failure? |
|
Definition
|
|
Term
| Is diaphroesis a sig of left or right heart failure? |
|
Definition
|
|
Term
| S4 can be caused by a number of conditions, most commonly... |
|
Definition
| hypertension, CAD, and diastolic dysfunction |
|
|
Term
| What is the most common cause of right heart failure? |
|
Definition
|
|
Term
| What are the NYHA classifications for CHF? |
|
Definition
| I= no symptoms with normal activities; II=slight limitation of activities; III= only comfortable at rest; IV= symptoms present at rest |
|
|
Term
| What are the AHA/ACC CHF stages? |
|
Definition
| A= at high risk for developing HF, B= structural heart disease is present but no symptoms, C= prior or current symptoms of heart failure, D= refractory heart failure |
|
|
Term
| What is the treatment for stage C heart failure? |
|
Definition
| full range of heart failure drugs (ACEI, ARB, beta blockers, and diuretics), and sodium restriction |
|
|
Term
| What is the treatment for stage D heart failure? |
|
Definition
| mechanical circulatory support, continuous inotropes, cardiac transplantation, or hospice care |
|
|
Term
| What is the cause of pulmonary congestion in diastolic dysfunction? |
|
Definition
| increased hydrostatic pressure (activation of the renin-angiotensin-aldosterone system is usually not prominent) |
|
|
Term
| What will CXR of CHF show? |
|
Definition
| cardiomegaly, pulmonary vascular congestion (dilated vessels, interstitial or alveolar edema, kerley-b lines) |
|
|
Term
| Is there ever an indication to do cardiac cath in a pt with CHF? |
|
Definition
| yes; if there is suspicion of concurrent MI |
|
|
Term
| Name two common beta blockers used to treat heart failure? |
|
Definition
| carvedilol or metoprolol succinate |
|
|
Term
| Results of the SOLVD trial= |
|
Definition
| ACEIs decrease mortality and hospitalization with pts with class II-IV CHF; however 1% of people stop the ACEI because of the cough |
|
|
Term
| results of the CHARM study= |
|
Definition
| ARBs have a similar effect on hospitalization and cardiovascular mortality as ACEis |
|
|
Term
| What are the results of the COPERNICUS trial? |
|
Definition
| carvedilol, a mixed alpha and beta blocker, decreases mortality and hospitalization in class I-IV CHF |
|
|
Term
| What are the results of the RALES trial? |
|
Definition
| spironolactone decreased mortality in patients with class III and IV CHF by 30% when given WITH ACEIs or diuretics +/- digoxin |
|
|
Term
| What were the results of the EPHESUS trial? |
|
Definition
| shows that eplerenone confers similar benefits of spironolactone in heart failure with a decreased incidence of side effects such as gynecomastia and impotence |
|
|
Term
| What were the results of the A-HeFT study? |
|
Definition
| hydralazine and isosorbide dinitrate is beneficial in pts with symptomatic CHF; a study ofafrican americans demonstrated a 43% decrease in oneyear mortality |
|
|
Term
| What were the results of the DIG trial? |
|
Definition
| digoxin yields sympomatic relief in CHF but has no significant effect on decreased mortality and may increase mortality in women |
|
|
Term
| Name some causes of high output heart failure? |
|
Definition
| thyrotoxicosis, severe anemia, Paget's disease, beriberi and AV fistulas |
|
|
Term
| How do you treat diastolic dysfunction heart failure? |
|
Definition
| diuretics (decrease afterload), CCBs (induce brady and fascilitate myocardial relaxation), beta blockers (induce mild brady and inhibits coronary remodeling), NTG (decrease preload and dilates large coronary arteries), antiarrhythmics (if indicated) |
|
|
Term
| What are some nonpharmacologic interventions useful for CHF? |
|
Definition
| weight loss, sodium restriction (<2g/day), and fluid restriction (<1.5 L/day) |
|
|
Term
| What is the incidence of HTN in the elderly? |
|
Definition
|
|
Term
| What percent of HTN goes undiagnosed? |
|
Definition
|
|
Term
| What percent of HTN is "essential" or "primary"? |
|
Definition
|
|
Term
| What are some risk factors for developing essential hypertension? |
|
Definition
| age, DM, obesity, family history, diet (salt, alcohol, fat), lifestyle (inactivity, stress), major depression, ethnicity |
|
|
Term
| Which ethnicities have the highest and lowests risk of developing essential hypertension? |
|
Definition
| african american > caucasian=hispanic > asian |
|
|
Term
| What are some secondary causes of hypertension? |
|
Definition
| renal disease, drug effects, endocrine disorders, pregnancy, aortic coarctation, obstructive sleep apnea |
|
|
Term
| What are some renal diseases that can result in HTN? |
|
Definition
| fibromuscular dysplasia in young women, atherosclerotic disease, renal parenchymal disease (polycystic kidney disease, and renal cell carcinoma) |
|
|
Term
| What are some drugs that can cause HTN? |
|
Definition
| OCPs, corticosteroids, COX-2 inhibitors, amphetamines, epoetin alfa (epogen), lead poisoning |
|
|
Term
| What are some endocrine disorders that can cause HTN? |
|
Definition
| cushing syndrome, hyperaldosteronism, pheochromocytoma, hyperthyroidism, hyperparathyroidism, PCOS, acromegaly |
|
|
Term
|
Definition
| diagnosis is based on the mean of two or more seated readings on each of three or more encounters; the diagnosis is valid if pts are >18 yoa, have no acute illness, and have no 2ndary causes (diabetes, renal failure) |
|
|
Term
| When should you be suspicious of secondary hypertension? |
|
Definition
| pt is < 20 or >50; sudden-onset or severe hypertension, has hypertension that is refractory to treatment or has a suggestive H and P |
|
|
Term
| Which patient population should you avoid calcium channel blockers to treat HTN and why? |
|
Definition
| women; increased risk of CV mortality |
|
|
Term
| What are the JNC 7 BP goals? |
|
Definition
| <140/90 unless they have diabetes or renal disease (<130/90) |
|
|
Term
|
Definition
|
|
Term
|
Definition
| diuretics, beta blockers, ACEIs/ARBs, aldosterone antagonists |
|
|
Term
|
Definition
| beta blockers, ACEIs, aldosterone antagonists |
|
|
Term
| HTN + high risk for CAD = |
|
Definition
| duretics, beta blockers, ACEIs, calcium channel blockers |
|
|
Term
|
Definition
| diuretics, beta blockers, ACEIs/ARBs, calcium channel blockers |
|
|
Term
| Chronic renal failure + HTN= |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
| What are the lifestyle recommendations for patients with HTN? |
|
Definition
| weight loss, sodium restriction <2.6 g/day, exercise, 1 drink/day for women or 2 drinks/day for men, and eating a diet high in fruits and vegetables and limited in saturated fat |
|
|
Term
| What trial proves that thiazides are the best first line therapy for HTN? |
|
Definition
|
|
Term
| Why are AA more susceptible to HTN? |
|
Definition
| they may have decreased nitric oxide levels and may be more sensitive to a high-salt diet than other groups |
|
|
Term
| Results of the ASCOT trial? |
|
Definition
| calcium channel blocker therapy (amlodipine) +/- AEIs decreases teh risk of stroke and heart attack in comparison to beta blockers +/- thiazides; statin therapy decreases CV events without regard to serum cholesterol level |
|
|
Term
| What are the features of hypertensive retinopathy? |
|
Definition
| arteriosclerotic narrowing, AV nicking, ischemic changes ("cotton-wool" spots), hemorrhages, exudates, papilledema, visual acuity loss (if the macula is involved) |
|
|
Term
| What is the mean age of onset for infective endocarditis? |
|
Definition
|
|
Term
| What is the mortality rate for infective endocarditis? |
|
Definition
|
|
Term
| What factors predispose to infective endocarditis? |
|
Definition
| local hemodynamic abnormalities, presence of endothelial damage, the presence of circulating bacteria and the status of the host's immune system |
|
|
Term
| What organism is the main cause of acute endocarditis? subacute? |
|
Definition
| infection of normal heart valves with s. aureus; infection of abnormal heart valves with S. viridans |
|
|
Term
| What are some findings on physical exam of infective endocarditis? |
|
Definition
| changing murmur; splenomegaly |
|
|
Term
| Name some risk factors for infective endocarditis? |
|
Definition
| rheumatic heart diseae, aortic valve disease, mitral valve prolapse, congenital valve abnormalities, the presence of foreign bodies (pacemakers, prosthetic valves), senile calcification, poor dentition and a history of IVDU |
|
|
Term
| What are some complications associated with infective endocarditis? |
|
Definition
| CHF, embolization, glomerulonephritis, anemia, and myocardial abscess formation |
|
|
Term
| What gender is more commonly affected by IE? |
|
Definition
|
|
Term
| What are the etiologies for culture negative endocarditis? |
|
Definition
| haemophilus, actinobacillus, cardiobacterium, eikenella, kingella |
|
|
Term
| What are some cause of native valve endocarditis? |
|
Definition
| the most common causes are strep spp and enterococcus |
|
|
Term
| What are causes of presthetic valve endocarditis? |
|
Definition
| early= staph epidermidis; late= same as native valve |
|
|
Term
| What organisms cause post surgical endocarditis? |
|
Definition
| gram negative species or enterococcus |
|
|
Term
| Organisms responsible for endocarditis secondary to IVDU? |
|
Definition
| s aureus; consider this agent in the presence of a tricuspid valve lesion |
|
|
Term
| Name some fungi and atypical bacteria that can cause IE? |
|
Definition
| candida or aspergillus; rickettsia, chlamydia |
|
|
Term
| What labs should you get for IE? |
|
Definition
| CBC, ESR, UA, RF, at least two sets of blood cultures |
|
|
Term
| What does the CBC show in IE? |
|
Definition
| leukocytosis in acute; moderate anemia in subacute |
|
|
Term
| What duke criteria do you need to make a dx of IE? |
|
Definition
| two major, one major with three minor, or five minor |
|
|
Term
| What are the major criteria for IE? |
|
Definition
| persistently positive blood cultures; evidence of endocardial involvement or new valvular regurge |
|
|
Term
| What is the definition of persistently positive blood cultures? |
|
Definition
| two or more positive cultures sperated by at least 12 hours, three or more cultures at least one hour apart or 70% of cultures positive if four or more are drawn |
|
|
Term
| What are hte minor criteria for IE? |
|
Definition
| fever >38C, vascular phenomena, immunologic phenomena, predisposing heart abnormality or IVDU, + blood cultures, + echo |
|
|
Term
| What are some vascular phenomena associated with IE? |
|
Definition
| arterial emboli, janeway lesions, pulmonary emboli, mycotic aneurysms, intracranial hemorrhage |
|
|
Term
| What is a janeway lesion? |
|
Definition
| painless lesion on the palms and soles 2ndary to embolization |
|
|
Term
| What are some immunologic phenomena associated with IE? |
|
Definition
| osler's nodes, glomerulonephritis, +RF, roth spots |
|
|
Term
|
Definition
|
|
Term
|
Definition
| immunologic phenomena causing painful nodes on the tips of the fingers or toes |
|
|
Term
| Heart valvular dysfunction requiring surgery is common with which class of organisms? |
|
Definition
|
|
Term
| What is the treatment for IE? |
|
Definition
| 4-6 weeks of high dose IV antibiotics |
|
|
Term
| What is empiric treatment of IE? |
|
Definition
| vancomycin (traditionally beta lactam with two weeks of aminoglycoside for synergy, can still use aminoglycoside with vanc) |
|
|
Term
| When is surgery indicated for IE? |
|
Definition
| severe, refractory CHF; treatment resistant, infection of prosthetic valve, suspected fungal infection, recurrent embolic events, progressive intracardiac spread of infection |
|
|
Term
| What abx can prophylax pts with valvular abnormalities against IE when getting dental procedures? |
|
Definition
| amoxicillin or clarithromycin |
|
|
Term
| Syncope with head turning, tight collars or shaving= |
|
Definition
| carotid sinus hypersensitivity |
|
|
Term
| syncope with arm exercise= |
|
Definition
| subclavian steal syndrome |
|
|
Term
| "drop attacks" or neurogenic causes of syncope= |
|
Definition
| TIAs of the vertebrobasilar circulation (very large strokes of the antior circulation can lead to LOC but these patients will also have neurologic deficits if and when they arise) |
|
|
Term
| What is the definition of orthostatic hypotension? |
|
Definition
| systolic BP will decrease at least 20 mmHg within 2-5 minutes after the patient changes position from supine to standing |
|
|
Term
| What is the sensitivity of Holter monitoring? |
|
Definition
|
|
Term
| How do you treat vasovagal syncope? |
|
Definition
| avoidance of triggers, beta blockers, anticholinergics, or pacemaker placement |
|
|
Term
| In sudden death in pts less than 35, what is the cause? |
|
Definition
| 1/3 are idiopathic; 1/2 are cardiac |
|
|
Term
| What is the typical age of pts presenting with valvular heart disease? |
|
Definition
| 7th decade; except for mitral stenosis which presents in the fourth and fifth decades |
|
|
Term
| What is the leading cause of valvular heart disease? |
|
Definition
| degenerative heart disease; MCly calcific stenosis related to atherosclerosis |
|
|
Term
| What are some risk factors for aortic stenosis? |
|
Definition
| rheumatic heart disease, congenital stenosis/bicuspid valve, age-related degeneration |
|
|
Term
| What is the clasic triad of symptoms for aortic outflow obstruction? |
|
Definition
| angina, syncope and heart failure |
|
|
Term
| What is the mortality rate for symptomatic aortic outflow obstruction? |
|
Definition
| depends on the symptoms; 50% mortality at 5,3, and 2 yrs respectively for angina, syncope, and heart failure |
|
|
Term
| What are findings on physical exam of aortic outflow obstruction? |
|
Definition
| pulsus parvus et tardus, sustained apical beat; S 4 and soft S2 heart sounds |
|
|
Term
| Describe the murmur of aortic stenosis? |
|
Definition
| midsystolic crescendo-decrescendo murmur at 2nd interspace radiation to carotids with a musical apical component, systolic ejection click |
|
|
Term
| What is the musical apical componenet of aortic stenosis murmur called? |
|
Definition
|
|
Term
| T/F Intensity of murmur relates to severity of aortic stenosis. |
|
Definition
|
|
Term
|
Definition
| systolic diamond shaped harsh murmur at the apex and left sternal border, with poor transmission to the carotids; earlier and longer with decreased left ventricular size (valsalva or standing), decreased with increased left ventricle size (squatting) |
|
|
Term
| What is the treatment for aortic stenosis? |
|
Definition
| avoid afterload reduces (such as vasodilators and ACEIs) and Beta blockers; gentle diuretics for congestive symptoms, consider antibiotic prophylaxis |
|
|
Term
| When is ballon valvuloplasty used for AS? |
|
Definition
| as palliation for poor surgical candidates |
|
|
Term
| What are the critical values for evaluating aortic stenosis? |
|
Definition
| aortic orifice <0.5 cm2; or pressure gradient > 50mmHg |
|
|
Term
| What is the treatment for HOCM? |
|
Definition
| avoid strenuous exercise; beta blockers may be used to decrease outflow obstruction; surgical myomectomy or pacemaker placement |
|
|
Term
| What aortic valve diseases can cause aortic insufficiency? |
|
Definition
| rheumatic heart disease, endocarditis, congenital bicuspid valve |
|
|
Term
| What are some aortic root diseases that can cause aortic insufficiency? |
|
Definition
| HTN, ehlers-Danlos, Marfan's, collagen vascular disease, vasculitis (Takayasu's, giant cell), aortic dissection, syphilitic aortitis, idiopathic aortic root dilation, subaortic VSD, trauma |
|
|
Term
| What are symptoms of chronic aortic insufficiency? |
|
Definition
| gradual onset angina, dysnpea, orthopnea, PND |
|
|
Term
| What are some physical exam signs of aortic insufficiency? |
|
Definition
| signs of LVH and left heart failure, increase in stroke volume, widened pulse pressure, laterally displaced PMI,possible brachial pulsus bisferiens |
|
|
Term
| Twin pressure peaks assoc with aortic insufficiency= |
|
Definition
| brachial pulsus bisferiens |
|
|
Term
| What is the murmur of aortic insufficiency? |
|
Definition
| high pitched, blowing diastolic murmur over left sternal border that is loudest when leaning forward; austin flint murmur, midsystolic murmur at the base due to high volume flow |
|
|
Term
| What is an Austin Flint murmur? |
|
Definition
| similar to murmur of MS but without opening snap; assoc with aortic insufficiency |
|
|
Term
| How do you treat aortic insufficiency if aortic valve replacement is not possible? |
|
Definition
| afterload reducse (vasodilators such as nifedipine and hydralazine), diuretics, and/or digoxin; consider endocarditis prophylaxis |
|
|
Term
| How do you treat acute decompensation of aortic insufficiency? |
|
Definition
| afterload reduces (nitroprusside) and positive inotropes (dobutamine) |
|
|
Term
| Name the typical valvular abnormalities of rheumatic heart diseaes? |
|
Definition
|
|
Term
| What are some causes of mitral stenosis? |
|
Definition
| rheumatic heart disease, congenital stenosis, cardiac myxoma, connective tissue disease (SLE) |
|
|
Term
| What are the symptoms of mitral stenosis? |
|
Definition
| right or left heart failure symptoms |
|
|
Term
| What is the murmur associated with mitral stenosis? |
|
Definition
| mid diastolic rumble with opening snap at the apex |
|
|
Term
| How do you tell the difference between mitral stenosis and tricuspid stenosis? |
|
Definition
| mitral stenosis does not change with inspiration; vs tricuspid stenosis which will increase with inspiration |
|
|
Term
| How do you treat mitral stenosis/ |
|
Definition
| avoid inotropic agents; consider endocarditis prophylaxis |
|
|
Term
| How do you treat grade I mitral stenosis? |
|
Definition
| sodium restriction, diuretics, anticoagulants, digitalis |
|
|
Term
| How do you treat grade II mitral stenosis? |
|
Definition
| same as grade I but consider balloon valvuloplasty if no improvement |
|
|
Term
| How do you treat grades III/IV mitral stenosis? |
|
Definition
| BV or for refractory disease; valve replacement |
|
|
Term
| What percent of the population has MVP and what predisposes people to have it? |
|
Definition
| 7%; young women or marfan's syndrome |
|
|
Term
| What is the murmur associated with MVP? |
|
Definition
| late systolic murmur with midsystolic clikc (Barlow's syndrome) valsalva leads to an earlier and longer murmur |
|
|
Term
| What is the treatment for MVP? |
|
Definition
| don't treat unless symptomatic; routine prophylaxis not recommended and reserved only for high risk patients |
|
|
Term
| What three things can be affected to cause mitral regurg? |
|
Definition
| cusp diseae, cordae tendineae dysfunction, mitral annular expansion |
|
|
Term
| What causes cusp disease leading to mitral regurg? |
|
Definition
| rheumatic heart disease, endocarditis, congenital cleft valve, myxomatous degeneration |
|
|
Term
| What causes chordae tendinae dysfunction leading to mitral regurge? |
|
Definition
|
|
Term
| What causes mitral annular expansion leading to mitral regurge? |
|
Definition
|
|
Term
| What are the symptoms of mitral regurge? |
|
Definition
| left heart failure signs that can progress to right heart failure |
|
|
Term
| What is the murmur of mitral regurge? |
|
Definition
| high-pitched holosystolic murmur at the apex radiating to the axilla; systolic thrill; laterally displaced hyperdynamic PMI |
|
|
Term
| What is the treatment of acute sympomatic mitral regurge? |
|
Definition
| afterload reduction (nitroprusside), inotroipc support (dobutamine), and surgical repair |
|
|
Term
| How do you treat chronic mitral regurg? |
|
Definition
| ACEIs, vasodilators/nitrates, diuretics, digoxin, anticoagulants |
|
|
Term
| How do you diagnose chronic bronchitis? |
|
Definition
| excessive bronchial secretion with productive cough for at least three months per year over two consecutive years |
|
|
Term
| What is the emphysema pattern associated with smoking vs alpha 1 antitrypsin def? |
|
Definition
| smoking= centrilobular; def= panacinar |
|
|
Term
| What imaging findings are pathognomonic for emphysema? |
|
Definition
| parenchymal bullae, subpleural blebs |
|
|
Term
| Symptoms of COPD occur when ___% of lung function is lost. |
|
Definition
|
|
Term
| Decreased breath sounds is associated with what type of COPD? |
|
Definition
|
|
Term
| Pursed lips is associated with what type of COPD? |
|
Definition
|
|
Term
| DOE is associated with what type of COPD? |
|
Definition
|
|
Term
| Cyanosis is associated with what type of COPD? |
|
Definition
|
|
Term
| Crackles is associated with what kind of COPD? |
|
Definition
|
|
Term
|
Definition
| hyperinflation, hyperlucency, loss of capillary-alveolar surface area, a flattened and depressed diaphragm, widened retrosternal air space and increased AP diameter |
|
|
Term
| CXR of chronic bronchitis= |
|
Definition
| ther are no specific findings for chronic bronchitis on CXR or PFTs except those assocaited with comorbid emphysema |
|
|
Term
| What are the findings of COPD on ABG? |
|
Definition
| acute respiratory acidosis; as well as increased alveolar arterial oxygen gradient |
|
|
Term
| What is first line therapy for COPD? |
|
Definition
| anticholinergics (ipratropium) |
|
|
Term
| What is the teratment for acute exacerbation of COPD? |
|
Definition
| supplemental O2, hydration, IV or oral steroids, anticholinergics and beta agonists; antibiotics (TMP-SMX, cefuroxime) in the presence of concurrent infection |
|
|
Term
| What is the only therapy that can slow the disease process of COPD? |
|
Definition
|
|
Term
| What are indications for home oxygen for COPD? |
|
Definition
| PO2 <55mmHg or SaO2 88%; PO2 55-59 with symptoms of hypoxia (mental status changes, right sided heart failure from cor pulmonale, polycythemia) |
|
|
Term
| What are some complications that can result from COPD? |
|
Definition
| destruction of pulmonary vasculature>pulmonary hypertension>cor pulmonale; pneumonia; bronchogenic carcinoma |
|
|
Term
| What percent of CXRs have solitary pulmonary nodules and what percent of these are not malignancies? |
|
Definition
| 0.1-0.2% of CXRs; 60-90% do not represent a malignancy |
|
|
Term
| OF all solitary pulmonary noduls what percent are primary lung and what percent are mets? |
|
Definition
|
|
Term
| What percent of smokers develop lung cancer? |
|
Definition
|
|
Term
| What percent of lung cancers are caused by smoking? |
|
Definition
|
|
Term
| Smoking + what other factors can increase the risk of lung cancer? |
|
Definition
| asthma and vitamin E supplementation |
|
|
Term
| Besides smoking, what else can increase your risk of lung cancer? |
|
Definition
| radon exposure, environmental exposure (arsenic, asbestos, uranium, chromium) and first generation familial history |
|
|
Term
| What percent of patients with lung cancer are asymptomatic at the time of diagnosis? |
|
Definition
|
|
Term
| Why is it important to get a biopsy in the work up for lung cancer? |
|
Definition
| treatment and prognosis is predicated on whether the cancer is small cell or non small cell |
|
|
Term
| Name some complications from lung cancer? |
|
Definition
| superior vena cava syndrome, pancoast tumor, horner's syndrome, endocrine, recurrent laryngeal symptoms, effusions (pleural or pericardial) |
|
|
Term
| What is the treatment/prognosis of NSCLC? |
|
Definition
| surgical resection followed by radiation/chemo; early stage NSCLC is curable |
|
|
Term
| What is the treatment and prognosis of SCLC? |
|
Definition
| nonresectable but usually responsive to combination and radiation therapy; recurrence is common |
|
|
Term
| What is the definition of a chronic cough? |
|
Definition
| cough present for > 3 weeks |
|
|
Term
| % of 1/2 ppd smokers with chronic cough= |
|
Definition
|
|
Term
| 90% of chronic cough are caused by what causes? |
|
Definition
| GERD, asthma, smoking, postnasal drip, chronic bronchitis |
|
|
Term
| Name some less common causes of cough after the top 5 most commonl. |
|
Definition
| medication (ACEIs), airway hyperresponsiveness secondary to URI, malignancy, TB, aspiration, foreign bodies, occupational irritants, psychogenic factors, CHF, and irritation of cough receptors in the ear |
|
|
Term
| Which lung cancers have as strong association with smoking? |
|
Definition
| SCLC>squamous cell carcinoma |
|
|
Term
| Which lung cancer has a weak association with smoking? |
|
Definition
|
|
Term
| Which lung cancer has a moderate association with smoking? |
|
Definition
|
|
Term
| Name the different types of lung cancer and the % incidence? |
|
Definition
| SCLC (15-25); squamous (20), adeno (60), large cell (20), mesothelioma (3-5%), carcinoid (6) |
|
|
Term
| Where do carcinoids of the lung occur? |
|
Definition
|
|
Term
| Name some paraneoplastic syndromes with small cell lung cancer? |
|
Definition
| cushing's, SIADH, hypercalcemia, ectopic ACTH, peripheral neuropathy, lambert-eaton, SVC |
|
|
Term
| What is the 5 yr survival of SCLC? |
|
Definition
|
|
Term
| What is pulmonary osteoarthropathy? |
|
Definition
| clubbing, periostitis, arthritis |
|
|
Term
| What are some paraneoplastic syndromes of squamous cell carcinoma? |
|
Definition
| hypercalcemia from PTH-related peptide, hypertrophic pulmonary osteoarthropathy, SVC syndrome |
|
|
Term
| What are some paraneoplastic syndromes of adenoca of the lung? |
|
Definition
| hypertrophic pulmonary osteoarthropathy, thrombophlebitis |
|
|
Term
| What mutation is associated with adenoca of the lung? |
|
Definition
| Ras gene mutations in 30% |
|
|
Term
| Name some paraneoplastic syndromes of large cell carcinoma? |
|
Definition
| gynecomastia, galactorrhea, hypertrophic pulmonary osteoarthropathy |
|
|
Term
| How long does it take asbestos to cause mesothelioma? |
|
Definition
|
|
Term
| What lung cancer is very uncommon in african americans? |
|
Definition
|
|
Term
| What are some symptoms of carcinoid of the lung? |
|
Definition
| tachycardia, flushing, bronchial constriction, diarreha, cushing's syndrome |
|
|
Term
| What lung cancer has the best prognosis regardless of stage? |
|
Definition
| carcinoid (60-95% 5 yr survival) |
|
|
Term
| What are the most common cancers to metastasize to the lung? |
|
Definition
| colon, breast, renal, osteosarcoma, melanomas |
|
|
Term
| T/F Pleural effusions are often asymptomatic. |
|
Definition
|
|
Term
| Name some causes of transudative pleural effusion. |
|
Definition
| CHF, cirrhosis, nephrotic syndrome, peritoneal dialysis, SVC obstruction, myxedema, urinothorax, protein losing enteropathy, pulmonary embolism |
|
|
Term
| What are some causes of exudative effusion? |
|
Definition
| bacterial infection, neoplasm, pulmonary embolism with infarction, TB, viral infection, collagen vascular disease, pancreatitis, hemothorax, sarcoidosis, uremia, asbestosis, pericardial diseae, chylothorax, iatrogenic |
|
|
Term
| Name some causes of bloody pleural fluid. |
|
Definition
| neoplasm, TB, traumatic tap, pulmonary embolus, hemothorax |
|
|
Term
| What are some causes of pleural fluid with low glucose? |
|
Definition
| neoplasm, TB, empyema, RA |
|
|
Term
| What are some causes of lymphocytic pleural fluid? |
|
Definition
| viral infection, TB, malignancy |
|
|
Term
| What are some causes of milky pleural fluid? |
|
Definition
|
|
Term
| What are some physical exam findigns of pleural effusion? |
|
Definition
| decreased breath sounds, dullness to percussion and decreased tactile fremitus |
|
|
Term
| Pleural fluid with a very low glucose and negative gram stain== |
|
Definition
|
|
Term
| What studies should you get on pleural fluid? |
|
Definition
| CBC with diff, glucose, gram stain, protein and LDH ratios, amylase, pH, cytology |
|
|
Term
| What are "light's criteria"? |
|
Definition
| pleural fluid protein/serum protein >0.5 and pleural fluid LDH/serum LDH >0.6 (or pleural fluid LDH > 2/3 the upper limit of normal serum LDH) are suggestive of an exudate as opposed to a transudate |
|
|
Term
| High amylase in pleural fluid indicates.... |
|
Definition
| esophageal rupture, pancreatic pleural effusion or malignancy |
|
|
Term
| What is the normal pH of pleural fluid? What is considered acidic? |
|
Definition
|
|
Term
| An acidic pleural fluid pH can be due to... |
|
Definition
| empyema, rheumatoid pleurisy, tuberculous pleurisy or malignancy |
|
|
Term
| What is a low pleural fluid glucose? |
|
Definition
|
|
Term
| What symptoms characterize atypical pneumonia as oppossed to typical pneumonia? |
|
Definition
| atypical= dry cough, myalgias, headaches, sore throat, and pharyngitis |
|
|
Term
| What is empiric treatment for CAP? |
|
Definition
| flouroquinolones or ceftriaxone/azithromycin |
|
|
Term
| pneumonia with "rust colored sputum"= |
|
Definition
|
|
Term
| pneumonia with "currant-jelly" sputum? |
|
Definition
|
|
Term
| pneumonia with cold agglutinins= |
|
Definition
|
|
Term
| pneumonia with increased LDH= |
|
Definition
|
|
Term
| Breath sounds associated with pneumonia= |
|
Definition
| decreased vesicular but increased bronchial |
|
|
Term
| What are the breath sounds associated with pleural effusion? |
|
Definition
| decreased breath sounds with inspiratory crackles |
|
|
Term
| What antibiotics is commonly used in patients with pneumonia to cover for legionella? |
|
Definition
|
|
Term
| How do you determine whether to hospitalize a patient with pneumonia? |
|
Definition
|
|
Term
| When can a patient with pneumonia on IV antibiotics switch to oral antibiotics? |
|
Definition
| if they have been afebrile for 24 hrs |
|
|
Term
| What can be done to loosen consolidation and improve aeration in patients with pneumonia? |
|
Definition
| incentive spirometry, ambulation, CPT, and hydration |
|
|
Term
| What are the suspected pathogens in outpatient CAP otherwise healthy? |
|
Definition
| S pneumo, mycoplasma neumo, H. flu, virus |
|
|
Term
| What should you use to treat outpatient CAP? |
|
Definition
| macrolide (clarithromycin or azithromycin), doxycycline, or beta lactam |
|
|
Term
| What kind of corganisms cause CAP in pts over 60 or with comorbidities? |
|
Definition
| S pneumo, H flu, aerobic gram negative rods (e coli, enterobacter, klebsiella), S aureus, legionella, viruses |
|
|
Term
| How do you treat CAP with age >60 or with comorbidities? |
|
Definition
| second generation cephalosporin (cefuroxime) or amoxicillin/clavulanate; add azithromycin if atypicals are suspected; alternatively flouroquinolone monotherpay |
|
|
Term
| What are some suspected pathogens in CAP requiring hospitilization? |
|
Definition
| S pneumoniae, H. flu, anaerobes, aerobic GNRs, legionella, chlamydia, mycoplasma, pseudomonas |
|
|
Term
| How do you treat CAP requiring hospitilization? |
|
Definition
| azithromycin with a second or third generation cephalosporin (cefotaxime or ceftriaxone) or a beta lactam with a betalactamase inhibitor; alternatively flouroquinolone monotherapy |
|
|
Term
| What are some causes of nosocomial pneumonia? |
|
Definition
| GNRs, including pseudomonas, S aureus, legionella and mixed flora |
|
|
Term
| Whom do you vaccinate against pneumococcus? |
|
Definition
| >65; children 2-23 months; chronic systemic illness, decresaed immune function, alaskan natives and selected native american populations |
|
|
Term
| What percent of patients with pneumococcal pneumonia get bacteremia? |
|
Definition
|
|
Term
| T/F Pneumonia increases the risk of MI and stroke. |
|
Definition
|
|
Term
| What is the definition of acute renal failure? |
|
Definition
| abrupt decrease in renal function leading to retention of creatinine and BUn often accompnied by oliguria or anuria |
|
|
Term
| What is the definition of oliguria? |
|
Definition
|
|
Term
| What is the definition of anuria? |
|
Definition
|
|
Term
| How do you calculate the FeNa? |
|
Definition
| (urine Na X plasma Cr)/(plasma Na X Urine Cr) X 100 |
|
|
Term
| When do you treat acutre renal failure with bicarb? |
|
Definition
| if HCO3- is equal to or less than 16 or serum pH is <7.2 |
|
|
Term
| What dietary restriction should you impose on pts in acute renal failure? |
|
Definition
| K less than or equal to 40 mEq/day; PO4 <800 mg/day |
|
|
Term
| After relieve urinary obstruction, what complication should you look out for? |
|
Definition
| posobstructive diuresis can lead to inappropriate loss of fluid an delectrolytes |
|
|
Term
| Name some causes of prerenal ARF? |
|
Definition
| hypovolemia, systemic vasodilation, renal vasoconstriction (ACEI/ARBs), decreased cardiac output |
|
|
Term
| What are some types of intrinsic renal failure? |
|
Definition
| acute tubular necrosis, acute interstitial nephritis, renovascular, glomerular injury |
|
|
Term
| What are some causes of ATN? |
|
Definition
| ischemia, contrast dye, amnoglycosides, amphotericin |
|
|
Term
| What are some causes of acute interstitial nephritis? |
|
Definition
| beta lactams, sulfa drugs, NSAIDs |
|
|
Term
| What are some renovascular causes of intrinsic ARF? |
|
Definition
| HUS/TTP, DIC, vasculitis, cholesterol emboli |
|
|
Term
| Crystal precipitation in tubules causes what type of renal failure? |
|
Definition
| postrenal acute renal failure |
|
|
Term
| What are some distinguishing features of lab workup for prerenal ARF? |
|
Definition
| BUN/CR >20; FeNa <1%; urine osmolarity >500 mOsm/kg; bland UA with no hyaline casts |
|
|
Term
| How do you treat prerenal ARF? |
|
Definition
| fluid repletion in small defined boluses and frequent monitoring of electorlytes and acid base balance |
|
|
Term
| What are the distinguishing features of ARF due to intrinsic renal disease on lab workup? |
|
Definition
| BUN/Cr<20; FeNa >2%; urine osmolarity <350 mOsm/kg; UA shows muddy/granular casts +/- RBCs/protein in ATN; +eosinophils if AIN from antibiotics |
|
|
Term
| What are the distinguishing features of post renal ARF on laboratory workup? |
|
Definition
| bland UA +/- RBC casts if nephrolithiasis; renal U/S identifies upper an dlower tract obstruction and can also distinguish acute from chronic renal failure |
|
|
Term
| What are indications for dialysis? |
|
Definition
| acidosis unresponsive to medical therapy, electrolyte abnormalities (K >6.5 mEq/L), ingestions (methanol, ethylene glycol), overload of fluid, uremic symptoms (pericarditis or encephalopathy) |
|
|
Term
| What is the defnition of CKD? |
|
Definition
| three or more months of reduced GFR (<60 mL/min/1.73m2 and/or kidney damage (abnormal pathology, blood/urine tests, or imaging) |
|
|
Term
| What percent of americans ahve CKD? |
|
Definition
|
|
Term
| When do symptoms develop from CKD? |
|
Definition
| usually around stage 3 or 4 |
|
|
Term
| What are some general symptoms of CKD? |
|
Definition
| anorexia, N/V, fatigue, pruritus, metallic taste in the mouth |
|
|
Term
| What are some findings of physical exam suggestive of chronic kidney disease? |
|
Definition
| fetor uremicus (breath smelling of urine/ammonia), uremic frost, |
|
|
Term
| What are some cardiovascular complications/symptoms of CKD? |
|
Definition
| HTN, LVH, pericarditis, accelerated atherosclerosis, volume overload, CHF, hyperlipidemia |
|
|
Term
| What are some neurologic complications of CKD? |
|
Definition
| peripheral neuropathy, encephalopathy, seizures, stupor, coma |
|
|
Term
| What are soem hematologic issues seen with CKD? |
|
Definition
| anemia due to deceased production of EPO and also iron deficiency/anemia of chronic diseease |
|
|
Term
| Describe some metabolic poblems associated with CKD? |
|
Definition
| hyperkalemia, metabolic acidosis, hyperphosphatemia, hypocalcemia (due to vitamin D deficiency and binding with excess phosphate), secondary hyperparathyroidism leading to osteoporosis |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| GFR <15; also caused ESRD |
|
|
Term
| When do you prepare pts with CKD for renal replacement therapy? |
|
Definition
|
|
Term
| What should you do to care for the cardiovascular health of pts with CKD? |
|
Definition
| ACEIs/ARBs for HTN with a BP goal of <130/80 (has been shown to decrease the progression of CKD), sodium restriction and/or loop diuretics to prevent volume overload; statins to lower LDL cholesterol (goal <100mg/dL) |
|
|
Term
| When do you give EPO for pts with CKD? |
|
Definition
| weekly injections if hemoglobin is <12 in females or less than 13.5 in males; given iron supplementation to maintaine sufficient iron stores (%transferrin saturation >20% and ferritin >100ng/mL) |
|
|
Term
| What medical things in general should pts with CKD avoid? |
|
Definition
| nephrotoxic drugs (NSAIDs, aminoglycosides, contrast), avoid blood draws on one arm and subclavian lines to preserve vasculature for future access |
|
|
Term
| What should pts with CKD do to prevent metabolic abnormalities? |
|
Definition
| dietary restriction of Na, K PO4 and Mg; bicarb or citrate if HCO3 <22; oral PO4 binders like calcium carbonate taken with meals and calcitriol for renal osteodystrophy |
|
|
Term
| What is renal replacment therapy? |
|
Definition
| hemodialysis peritoneal dialysis or renal transplant |
|
|
Term
| What is the definition of nephrotic syndrome? |
|
Definition
| severe proteinuria (>3.5 g/day) generalized edema, hypoalbuminemia, and hyperlipidemia |
|
|
Term
| What causes the hypercoagulability of nephrotic syndrome? |
|
Definition
| imbalance of clottin factors in the coagulation cascade (due to an overal decrease in anticoagulation proteins especially antithrombin 3 lost in the urine; and to increased hepatic synthesis of procoagulant proteins such as fibrinogen |
|
|
Term
| What are some complications associated with nephrotic syndrome? |
|
Definition
| hypercoagulability and infection |
|
|
Term
| What is typically the albumin level in nephrotic syndrome? |
|
Definition
|
|
Term
| What are some primary renal causes of nephrotic syndrome? |
|
Definition
| minimal change disease, focal segmental glomerulosclerosis (membraneous glomerulonephrtitis) |
|
|
Term
| What causes membraneous glomerulonephritis? |
|
Definition
| 75% idiopathic, but secondary casues include SLE, penicillamine, gold, NSAIDs, HBV, HCV, syphilis, and malignancy |
|
|
Term
| What systemic disease can cause nephrotic syndrome? |
|
Definition
| diabetic nephropathy (renal amyloidosis, SLE WHO class V) |
|
|
Term
| Nephritic sydnrome causes can be divided based on what lab value? |
|
Definition
|
|
Term
| Name some primary renal diseases that can cause nephritic syndrome with low complement. |
|
Definition
| postinfectious GN (membranoproliferative GN) |
|
|
Term
| Name some systemic diseases that can cause nephritic syndrome with low complement. |
|
Definition
| SLE WHO class III/IV, infectious endocarditis (HCV, cryoglobulinemia) |
|
|
Term
| What are some primary renal disease that cause nephritic syndrome with normal complement. |
|
Definition
| IgA nephropathy; rapidly progressive, ANCA-associated, pauci-immune glomerulonephritis (hereditary nephritis=alport's) |
|
|
Term
| What are some systemic disease that cause nephritic syndrome with normal serum complement levels? |
|
Definition
| SLE WHO class II (antibasement membrane disease=goodpastures, vasculitis= polyarteritis nodosa, microscopic polyarteritis, Wegener's granulomatosis, HSP; TTP, HUS) |
|
|
Term
| What is nephritic syndrome? |
|
Definition
| inflammatory disorder characterized by acute onset oliguria and ARF; hematuria, subnephrotic range proteinuria, hypertensiona nd edema are also present |
|
|
Term
| What are some signs and symptoms of nephritic syndrome? |
|
Definition
| proteinuria, hypertension, azotemia ( high BUN), RBC casts, oliguria, hypertension |
|
|
Term
| Besides UA and CMP, what else should you get to evaluate a patient with nephritic syndrome? |
|
Definition
| complement, ANA, ANCA, and anti-GBM antibodies should be measured; a positive ASO titer might be helpful |
|
|
